2024 Self-Audit Series #10: Nasal and Oral Inhaler Prescriptions

Nasal and oral inhaler prescriptions are frequently targeted for audit by all PBMs. Not only have these medications increased in cost but are frequently billed incorrectly, creating the potential for easy recoupments.

Pharmacy staff should be trained to accurately bill days’ supply for all inhalers. PAAS National® has created tools for our members to aid in the data entry process. Visit the Member Portal to access these resources – Nasal Inhalers Chart and Oral Inhalers Chart – and share with staff for easy reference when billing inhalers.

The following are examples of inhaler prescriptions at a higher risk of being flagged as refill too soon due to atypical dosing (when plan limits days’ supply to 30):

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

Symbicort® prescriptions 10.2 grams

  • Typical dosing: Two puffs twice daily = 30 days’ supply
  • Atypical dosing: One puff twice daily = 60 days’ supply

Azelastine HCL 0.1% nasal spray prescriptions

  • Typical dosing: One to two sprays in each nostril twice daily = 25 days’ supply
  • Atypical dosing: One spray in each nostril twice daily = 50 days’ supply

Whether the days’ supply is miscalculated, or the days’ supply exceeds the plan limit, the pharmacy could be in jeopardy of refilling too soon. Early refills are the most common audit discrepancy for inhalers and can result in full recoupment of “overbilled” claims. See PAAS’ Exceeding Days’ Supply Plan Limits for Unbreakable Package resource for information on how to navigate plan limits appropriately.

PAAS Tips:

  • Confirm the prescription quantity is complete. Many inhalers have two sizes available, so best practice is to confirm quantity includes puffs or grams based on NCPDP billing units
  • Check for “calculable instructions” to accurately bill the days’ supply
  • Use caution when switching albuterol inhalers, as not all are interchangeable or have the same package size
  • Consult the Oral Inhalers Chart or DailyMed for inhalers that have a “Beyond Use Date” (BUD). If an inhaler’s BUD is less than the calculated days’ supply, the days’ supply billed should reflect the BUD as the inhaler must be discarded appropriately after open date
  • Automatic refilling should not be used for “as needed” inhalers or inhaler prescriptions with days’ supply that exceeds plan limit
  • Monitoring and self-auditing your oral and nasal inhaler prescriptions regularly can prevent potential audit recoupments

PAAS Audit Assistance members can search the Newsline archive for keyword “2024 self-audit” to read previous articles in this series. If you have any questions on accessing the Member Portal, or need help adding employees so they have access, please contact us.

Dana Westberg, CPhT
Latest posts by Dana Westberg, CPhT (see all)